Summary Report for FSPSAs Initiated During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3040 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 49 50 106.879365 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 49 50 106.879365 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 13.367123 $648.3000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $21.0400 $21.0400
EXIT -EXIT EXIT ASSESSMENT 4 4 3.016667 $150.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 16.285714 $1221.4300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 18.285714 $1371.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1776.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 19 37.000000 $2775.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 6 12.000000 $900.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 55 84 142.955218 $9485.3600 $66.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 7.307502 $36537.0000 $4999.9300
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 257 288 325.564350 $16278.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 19 3.061648 $153.0700 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 37 37 34.362623 $859.0700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 119 128 242.892857 $12144.6400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 11 11 21.650002 $1082.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 10.809523 $270.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 76.519050 $3825.9700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 6.100000 $305.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 6.166667 $154.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 45 77.138890 $3856.9500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 9.650000 $482.5000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.533333 $38.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 82 159.715875 $7985.8000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 9 16.083333 $804.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.833333 $70.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 29 30 237.600001 $11879.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 39 226.428576 $11321.4200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 16.285715 $814.2900 $50.0000
INTR -T1013 INTERPRETER 117 140 416.750000 $20837.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 780 988 6474.783356 $64747.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 37.571429 $2703.6400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 5 5 34.609524 $2490.4900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.714286 $267.2800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 10.052381 $723.3700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.857143 $133.6400 $71.9600
TRAV -TRAVS Travel by mile 789 1012 6521.183355 $2901.9300 $0.4400
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Subtotal (Total Children Is Unduplicated) 864 2906 14983.224752 $203901.3900 $13.6100
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Total 3040 15233.059335 $213386.7600 $14.0100
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Number of Children (Unduplicated) With at Least One Authorization 912